Form Epa 4322 Onsite Sewage Treatment Systems (Supplement To Form A-B12)

Form Epa 4322 Onsite Sewage Treatment Systems (Supplement To Form A-B12) - Ohio Epa

State of Ohio Environmental Protection Agency

Division of Surface Water

Division of Environmental & Financial Assistance

Supplement to Form A – B12

Onsite Sewage Treatment Systems

Site Evaluation

FOR AGENCY USE ONLY

Date Received:

I. Applicant:

Applicant:

Mailing Address:

City:

State:

Zip:

Phone:

(

)

Fax:

(

)

Email:

II. Owner: (if different than Applicant)

Property Owner:

Mailing Address:

City:

State:

Zip:

Phone:

(

)

Fax:

(

)

E-mail :

III. Project Location:

Project Name:

Acres:

County:

Township/City:

Street Address:

Parcel Number:

Proposed Facility:

IV. Water Source:

Well:

New

Existing

Public System:

Other:

V. Wastewater Sources: (Check All That Applies)

Restroom(s)

Kitchen

Floor Drain(s)

Water Softener

Sink(s)

Swimming Pool Backwash

Dish Washer

Industrial Process Water*

Clothes Washer

Other(Please Specify):

Shower(s)

* Not typically permitted for discharge to soil absorption systems – Contact district office for disposal options

VI. Brief Project Description:

EPA 4322 (10/09)

Form B12

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Form Epa 4322 Onsite Sewage Treatment Systems (Supplement To Form A-B12) - Ohio Epa

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